Brents IT Blog

Random thoughts by an IT GOAT

NAVIGATION - SEARCH

An honest review of EclinicalWorks

24. June 2010 22:17 / Brent / EHR . General . HIMSS . MSSQL . SAN . VoIP . Windows Server 2003 / Comments (24)

Just some background:

We have been on Medical Manager for 10+ years.  Upgrade after upgrade went relatively smoothly.  We even migrated to a new box about 6 years in.  We went and looked at GE Centricity and had an indepth onsite review of Sage’s new product, Intergy.  Intergy was to replace the aging and no longer supported Medical Manager product.  Long story short, after several acquisitions, Sage Software ended up owning Medical Manager.

We have been running ECW( EclinicalWorks ) for over a year.  We have been through several upgrades and I personally have an in-depth knowledge of the whole architecture.

ECW is made up of several servers working in unison.  First you have the main database server, then two slave database servers, one for reporting from the application and an optional one for dedicated custom reporting that’s not completely baked as a product but will give you some useful information.  Next you have application servers, the number of application servers you have will depend on users.  Then there are three component servers:  One for FTP/File sharing, One for interfaces, One for faxing.  You then have the option of having a test server that comprises all of the above servers on one server.  Its essentially where you “test” new versions of the software or ideas, we also use it for training. 

ECW has a major flaw, now I see this as a flaw because it’s a redundancy and data availability thing.  The flaw is the fact that the desktop applications will only read and write the main database server.  This means that all the load is on this server, if its not up to snuff, your slower than a turtle.  Random freezing and slowness will plague you.  The next major issue is that they run that monstrosity they call a database in MyASM by default.  MyASM is ok, but when you need performance, especially when the database design is bad or faulty, INNODB is the only way to go!  So if you haven’t yet, get them to convert you to INNODB, you will see the performance increase overnight.  Let me end this paragraph on a good note, they also support MS SQL if you request it, my suggestion is to request it, but make sure you have weighed the cons of using MS SQL ( cost, feature loss, hardware and OS ).

Since ECW is using MySQL, apache and Tomcat, you can also run most of the servers on Linux, though they prefer windows.   I would recommend Linux if you know it, but make sure to choose a distribution they are ok with and you have staff that can support.

Clients are windows only.  They support Vista now and I believe by virtue of Vista they also support Windows 7.  If not, I know that ECW will work on it though.  The client is about 100MB+, so be ready when you upgrade, those packages are hard on your remote connections.   I also think the client is a kludgy.  Its bulky and they register all sorts of crap via command boxes when you install it.  I have run into several instances where things just won’t register properly which causes certain features to give random errors.  We generally reinstall the client manually to force a fix, though we have been successful with coping files and running the regs again.  It does communicate with the servers over HTTP or HTTPS.  It also users FTP to upload images and file sharing to download them(figure that one out).  FTP passwords are wide open on the network so make sure to deploy security on remote links( kinda obvious given its medical software, but just in case). 

The client itself is extremely comprehensive.  Our providers love the indepth abilities, our nurses love the details and tracking, our reports people like the ability to add fields and pull data till their hearts content.  So it’s a loss for IT but a win for staff and in the end, they win out.  Its not horrible though, so I would rate it one step below any of the office software from MS if that helps give an idea of problems.

The client is also bandwidth intensive and very chatty.  Be prepared to increase your site links to 3Mb or higher.  I would also recommend you enable QoS if you can.  Server side, the application sends queries for anything and everything the user sees.  This makes it very chatty, so be prepared for lots of small time traffic and heavy query loads on your server.

Speaking of connections, they say you are supposed to stay below 60ms on any client to server connection.  This latency requirement is tested during the implementation and recorded.  As far as client connectivity, you can use wireless or wired.  Just make sure to check your wireless card settings and ensure they do not decrease to save battery life.  I would also make sure you set a medium to high rate of Access Point ( AP ) switching.  This means that if another AP with a stronger signal is detected, the machine will swap to the next AP.  You will need to play with this setting to make sure it doesn’t swap to quickly though.  Users walking around the building may have issues if it swaps to much.

In order to fix some issues with the clients and the servers, we have deployed MS GPO’s to ensure certain settings are pushed to the clients.  These settings ensure the wireless works properly, Battery life is extended and various things users do when moving around do not put the tablet in sleep mode.  They also ensure that printers are assigned as lightly as possible to reduce startup and shutdown times.

When you first get ECW, the system will be blank.  You will need to fill in lots of stuff.  Be prepared for a lot of upfront data entry to get the system up to running speed.  Providers have to be added, staff have to be added and given permissions, security groups/templates need to be designed to ensure proper functionality, location information, billing tables, Medicaid/Medicare/Insurance information, and patient data migrated. 

I saved interfaces for last.  Most all health clinics have relationships with laboratories in the area.  The interface server discussed above will hold most of the data exported from your database and send it to the lab company of your choosing.  Keep in mind that most labs will pay for the interface to be built, but some will demand a certain level of volume in order to complete the transaction.  Make sure you and they know what each other want out of it and test it as much as you can before you make it live.

When signing with ECW there are a few contractual things you need to keep in mind.  Make sure to include deadlines.  Make sure to lock in interface pricing, maintenance pricing, license costs and labor costs.  Also include support expectations and response times if they will allow you.  Make sure to negotiate upgrade costs and if you want a feature not currently in the software, a deadline for inclusion.

If you think you are going to have trouble implementing it on your own, consider they provide hosting and that there are several companies out there that will provide consulting services that will keep you on track for your deployment dates.  You may also want to include penalties for failures.  Generally they will result in credits, but its nice to have a stick to go along with the carrot.

Final Thoughts

ECW is a good product.  While there are issues, every software has issues and none are perfect.  Remember to do as much preplanning as you can but also stick to your deadlines.  Keep on top of ECW for any additions to the software and installation/feature upgrades/fixes.  You are your best advocate.  Training your staff is very important.  Make sure to hold atleast two days of basic training and then follow up with another few days after they have had a week or so to use it in their day to day.  It is recommended that you have trainers onsite when a location goes live.

 

Few Notes on Hardware
-6130 Fujitsu scanners ( don’t bother with small card scanners )
-Logitech webcams, Business grade work the best and are supported
-Fujitsu tablets work fine and with the extended batteries, will last 6-7 hours on one charge.  This does not preclude other tablets, your providers may be more comfortable without a keyboard.  Motion has some great units that will fill that need.
-Any PC, we use Lenovo units with 4GB of RAM, will work.
-I have found that Brother 1270W monochrome lasers connected directly to the network work the best and fastest.  Though in some instances you may need two trays to allow for prescription paper.
-Servers are again up to you, they will provide a sheet with the requirements for each component.
-I do recommend SAN storage for any data drives if you go physical.  A SAN will give you flexibility, reliability and redundancy you cannot get from stand alone servers.

Tags : , , , ,

Comments (24) -

United States David

Thank you very much for an in-depth review from an IT perspective.  Most reviews I've read are from a physician point of view.  It's difficult to get providers to understand most issues revolve around the build or the back-bone and not necessarily the system.  This helps quite a bit!

United States Robert

For the most part I'd say your review is spot on... until I get to the part about eCW being a "good product".  Have the failures of IT caused such cognitive dissonance in us that we now just shrug at the massively hobbled architectures foisted upon as by companies and say, "Well, this must be what 'good' means"?

I've  worked as a consultant with 3 other places running eClinicalWorks.  eClinical *Works* [sic] if 1) the clinic is really small and can frequently self-manage it's own workflow when eCW explodes or has a problem; 2) When IT staff have a VERY hands-on approach and there are actual programmers and backend specialists with systems programming knowledge.

In case #2 (with a good sized server-side IT staff) I helped to move eCW to Linux.  In another case we were stuck with Windows, which is fine but setting up the tools to manage eCW's failings is harder.  IT staff should be empowered to completely manage 1) MySQL, 2) Any HL7 bridges, 3) Any data reporting.  In the case where we moved to Linux the staff (5 of them) engineered Catalina scripts to help manage certain things that eCW just seems to ignore.

In short, although 2 of the groups I worked with tell me eCW support has been a little more responsive generally if your tech staff aren't allowed to make the major system fixes eCW support will be a nightmare.

Be sure to actually have 3 database servers.  Replication load-balancing is a joke unless at least two of the servers are also very beefy.  Again, unless your clinic only has 5 doctors then you probably feel about eCW like you do any desktop app.

I've also been working with Centricity, Orchard and openMRS.  Frankly, for the staff that's necessary I'd rather get openEMR or VISTAS, tie it to Orchard for labs and spend a year tailoring an excellent interface.

The eCW client should be shown in software design classes as an example of FAIL.

I understand you've been stuck with eCW and are shrugging 'cause you're playing the cards you've been dealt.  However, I couldn't in good conscience (do I even have that???) suggest to unsuspecting clients that they're in for a nightmare if they choose this product.

HINT:  Technology is moving forward... this kind of tech was last peaked out in the late 1990s and early 2000s.

United States Robert

Just for the record I have no idea how well eCW ties to lab systems.  Nobody I know using Orchard has tied to eCW.

United States brentk

I cant say i agree 100% with your assesment, but you are correct that managing ecw on windows is a nightmare.  Generally their install teams dont know what the maintenance and modification teams are doing, so when something is modified/upgraded, the next person does not know nor do they account for the changes ramifications.

When we had Medical Manager, atleast the maintenance on it was light and could be performed through cron jobs.  While i myself have never used catilina, cron jobs and bash scripts usually do the trick for me.

In windows we use batch scripts and VMWare automation to deal with the various holes in their architecture.  As an admin, i am a bit suprised they have been able to scale it this long and not completely fail as an application.  I am also amazed that they can provided adequate hosting facilities to support as many provider offices as they do.  Personally, i wish i could move them to linux, but the team i have is not as familiar as me with the inner workings of linux.  Our management does not have the will to hire linux administrators to assist me and i feel uncomfortable moving them to it knowing that if i were to leave they would up a creek and completely dependent on ECW support.  

I completely agree regarding redundancy, its a joke in the default install.  MySQL doesnt support useful failover in windows.  Replication is just that, replication.   I am not sure if you are aware, but they are now supporting MSSQL.  We are planning on switching over to MSSQL shortly after we upgrade to version 9.  This will allow me to ensure enterprise redundnacy, resource utiliziation, full virtualization support and control over their application core, and will finally allow us to troubleshoot their inability to provide properly structured queries.

To answer your question, ECW does support HL7 interfaces for lab.  They are also using it for the Open Dental software they have integrated into their product.  I personally recommend Open dental, those application guys know what they are doing and have structured their small application to be quite optimized for all size organizations.

While i wish you the best of luck in your consulting, i hope the next time you run into an ECW installation, you are plesantly suprised by their progress.  Course i would not expect all their issues to go away, but as i say in the article, i havent seen any EHRs or software without problems of some kind.  Course while our tolerances may differ, eventually, if there is no improvement, the line will shift further from their favor and thus they will fade into the application abyss.

United States Robert

Thanks for your reply... I didn't mean to sound too overly harsh about your assessment, which was quite clear and good... it was just quite the wild ride dealing with eCW while I did.

I did compare and contrast my experience with OrchardSoft Lab Info Systems.  Orchard's product, Harvest, is very well engineered and the support is spectacular.

At the moment I've moved on to HTML5 and Drupal interface construction for openMRS with various Perl, C#, and some .NET reporting tools.  There's a LOT of normalization behind the scenes in this process--more than I'd realized when I started.  In the process some people I'm working with want to build a good default bridge for HL7 Lab Systems so we're doing that, too.

United States brentk

well i recognize that everyones assessment completely depends on their experience and usually the support staff they end up with.  We had a really good support person assigned to us and she was so good they pulled her and gave us another trainee.  The new guy was a complete waste of time and after much yelling, they finally gave us someone else.  Yes i agree everyone has to learn sometime, but when you have a language barrier and a learning curve, things will always end up being overly time consuming and most likely frustrating.

Anyhow, while i understood most of what you said, i am an admin, not a programmer, so i cannot comment to heavily on their inner workings, nor their HL7 methods.  Personally i havent played with HTML5 yet, still building internal asp(not .net ) applications for our company.  ASP.net has been out of reach given my time constraints for development.

It sounds like you found a good product to work with, thats always a good thing with regards to stress levels.  I try to do everything possible to reduce blood pressue spikes with ECW, having software thats easy to work with all the time would definitely be ideal.

United States steve

Eclinical customer service engineers with typical Indian accents are the nicest people. However, their response time is very slow. Then most of the time you find out it is the luck of the draw. If you end up with someone who is fixing the id scanner she will waste your time for hours tying up the computer only to tell you something is wrong with your computer and never admit that she has no clue of what she is talking about. Then you get guys/gals who are pros for fixing fax servers etc who fix stuff in no time.
Overall, you can tell it is a bunch of engineers who don't have any appreciation for the fact that you are in the service business that too in the medical field where it quickly old when you tell patients to call back since the system is down.

People that answer client service phones are cold and monotonous. When you are saying hey let me talk to someone about my ticket since it needs urgent attention, they will just tell you to buzz off with the typical east coast rudeness.

United States Tracy

ECW has been insanely debilitating for our office.  We are 2 months into it and I cannot say anything positive.  The software freezes regularly throughout the day, the errors are never ending and no matter how much we complain...."nice" IT guys don't get it.  Its very frustrating and I would absolutely not recommend this product to the worst doctor ever!

United States brentk

I cant say i havent heard that statement before.  The fact is that most places struggle with ecw at first.  Most of the time its stuff like you described that has to be cleared up by ECW directly.  Sometimes its not ECW related by ISP and hardware.  Generally they are pretty good at making sure the install environment is ready for an install though.

Slowness and freezing is almost always a database issue.  Have them check your servers slow query log to make sure nothing is getting stuck(they normally do this by default, but it never hurts to prod them).  Also, if you are using the server locally but the connection to the clients is wireless, make sure the slowness and freezing is occurring on both the wired and wireless clients.  If its just wireless clients, make sure the power settings on your wireless card are disabled and if you have more than one wireless access point(router), that your wireless cards affinity it set to medium or medium high.

If ECW is hosting your server, i would make sure your ISP(DSL, cable, T1) is capable of handling the traffic.  Might need to bump your speed up.

We interact with GE centricity users, intergy users, epic users(happiest), all of them have issues at one point or another, especially during a go live situation.  Epic of course has the best rating overall, but you could only get that if you partner with a hospital that has it(well worth it though).

United States Eileen

I have been struggling with eCW for 7 months. It is completely configured to the eCW's needs. There is absolutely no concern or structure for the clients needs. If you have a problem, you are required to "create your own ticket." To do that, you go to their website and choose between 9 options for what type of ticket you need. That takes you to 2 more choices from three more lists each to narrow down the direction of the tickets. So, 9 choices so far. Then you must give them a title for your problem, then a narrative (including attachments is needed). Then you must give them 2 contacts for when they call about the problem. That is so THEY are not inconvenienced when they call you in hours or days to work on the problem. Often, the techs only goal it to "close" the ticket. Sometimes you get great help, sometimes they give you ridiculous solutions. Of course, if you want to get help, they are happy to train you for additional fees. Our billing system has been a nightmare. The trainer can't make it work. She is kind enough to complete tickets when she can't complete training but they are never fixed.
I would be happy to give ANYONE thinking about this system a LONG list of questions to ask BEFORE you commit.

United States brentk

What you say is true, they require a ticket to be put in and yes it has a few fields.  I use google chrome, so many of the redundant fields are filled in for me with its form filler.

I can agree, billing has a long way to go.  Course if you think billing is a nightmare now, wait till ICD10 is required.  Anyhow, we have 12 full time billers and its all they do.  I would say their biggest complaint to me has been form creation/use problems.  We knew there was a lot of manual stuff they had to do when we bought ECW, so they generally dont gripe about that.

It sounds like what you really need is someone onsite that knows ECW in/out that doesnt give you the ECW line.  I can recommend a few groups out there that have the knowledge to get you on the right track, they can also follow up on the tickets for you and at least give you answers.  Get in contact with one of the below and i would bet the majority of the issues you are experiencing would go away.  

Disclaimer:
I only know these contacts through business conferences that cater to healthcare, i do not recieve anything from them by listing them here:

Cumberland Consulting: http://www.cumberlandcg.com/
Ciber: http://www.ciber.com
Beacon: http://www.beaconpartners.com
Orchestrate: http://www.orchestratehealthcare.com/

or search here(not all do ecw):
onlinebuyersguide.himss.org/results.asp

Or if you want to look around on your own, i recommend http://www.ecwusers.com/index.php

If you want to get a feel for the consultants, feel free to come to HIMSS next year and speak directly to several listed above.  I think its in Las Vegas for 2012.  There may also be a local healthcare conference you can attend, i know most of these companies go to more than just HIMSS.

United States IT Professional

Hi Brent,
I am hoping you can provide some feedback for an Eclinical scenario.

Company has four sites: A, B, C, and D. Site A is the host where the onsite Eclinical server resides. Sites B, C, and D connect back to site A via a private MPLS network that supports 6 Layer 3 QoS priority classifications. Company is running Eclinical application across the WAN as well as voice and other inter-office data with the following user counts and circuits speeds at each site:

Site A:
20 Users
2xT1 3Mbps Port and Access to MPLS with 768Kbps of the highest QoS Priority.

Site B:
4-6 Users
T1 1.5Mbps Port and Access to MPLS with 384Kbps of the highest QoS Priority.

Site C:
4-6 Users
T1 1.5Mbps Port and Access to MPLS with 384Kbps of the highest QoS Priority.

Site D:
4-6 Users
T1 1.5Mbps Port and Access to MPLS with 384Kbps of the highest QoS Priority.

Company reports that the remote locations have problems when retrieving stored files in the patient document screens and they get stuck on the hour-glass.

Can you share your thoughts on what the company should do to attempt in remedying this?

Thankfully,
Frustrated IT Professional

United States brentk

The issue is most likely on the scanning side.  Assuming that the users are scanning documents in, they are most likely scanning them in at to high a resolution which means large files.  The biggest offenders in this area are generally IDs, insurance cards, anything that requires color.  Most documents shouldn't be over 100KB unless they are multiple pages( i have seen 20MB faxes with 130 pages ).

The next possibility, given that you have QoS in place is if you are using Eclini- forms.  These are forms that patients sign in order to give consent for various clinical procedures.  Typically staff just scan them in from their old forms and valla you have large documents being transferred constantly to users.  All you would need to do is reconvert the documents to a smaller tif or jpg file and upload them again to the forms area.  For cleaner forms, recreate the form in word, create a PDF and save it to a tif file from PDF using acrobat(there are other ways if you don't have adobe acrobat).

Also side note:  Assuming site A's bandwidth listing is the end point connection for B, C, and D, the lines are over subscribed and so is the QoS.  The minimum recommendation is 1.5 per location, though personally i would go with 3Mb because of the scanning of images(assuming you scan images at remote locations even if using DFS).  The bottom line here would be to add another bonded T1 to site A and up the QoS in the highest priority.  Also, assuming the highest priority is VoIP, the second should be any traffic to ECW servers.  You may want to include the FTP server, though you might be better off moving it to queue 3.

Not sure what kind of routers you are using there, but we use mikrotik routers here and they have a feature called "torch" that allows you to see what traffic is passing, where it is going and speed/bandwidth.  I suppose you could do packet dumps with cisco.

Second side note:  if increased bandwidth costs are not an option, there are devices out on the market that will compress data streams.  I was recently introduced to silver-peak which offers a product that can cache data as well as compress it, thus addressing files that are continually sent back and forth, making them appear instantly.

United States angelc

I apologize if I entered this twice but I though I lost what I entered.

I would appreciate your opinion on this setup. I am comfortable with computers but am FAR from an expert regarding this level of IT. I am in a 10 provider practice. When we signed up for eCW, we were told for a practice between 10-29 providers that we needed 5 servers. Due to the cost and because we are right at the bottom with 10 providers, we went with 2 physical servers, each with 2 x 2.4 Quad Core Xenon processors,and 64 gb of RAM. 1 machine has the domain controller and EBO Server virtualized as 2 machines. The other machine has the interface, database, and application server virtualized as 3 machines. We also have a backup server and the fax server. The providers are using Lenovo X220 tablets with SonicWall access points. After about 1.5 weeks after our go live,  I have been happy with the performance so far.  Approximately 5% of time eCW freezes for 5-10 seconds. On rare occasions, it has to be shut down and restarted - usually when the MD keeps trying to click and click to get something going! It seems to be limited to the laptops although there are a few reports on the HP desktops.

Would getting an additional physical server to act as the database server help?
How difficult is it to change from MyASM to INNODB not that we are well into our go live?

United States Dr. Cynic

Our resident teaching clinics switched to eCW from another company's EMR last year.  And our experience has been a disaster.

Among the problems we've found with eCW:


1.) Falling flat on their (user inter)faces

Many computer users, including doctors and other health-care personnel, aren't very computer savvy.  They need and should expect a simple interface, where command buttons, menus, and keystrokes each do the same thing everywhere in the program.

eCW delights in inconsistency.  One example: the keystroke Alt-O (the underlined O in OK) will do the same thing as clicking the "OK" button in some windows but not in others.  There is no obvious reason why a button such as "OK" can't mean the same thing and behave the same way everywhere in the software, and plenty of reasons why it should - including making use and training a heck of a lot easier.  It also violates Microsoft's standards for user interfaces: keys, hotkeys, and buttons are supposed to work the same way everywhere in an application.

Another example is user defaults and favorites.  Some can be changed by the user and remain changed.  Some of them (such as allowing display of custom drug doses) can be changed by the user, but changes don't take effect until you log out and then log back in, and some of those changes (including display of custom drug doses) revert to the original default after the next logout-login.  Some of them, such as which facility the user is at, depends on where the workstation is, and an unwary user may log onto a computer and find that she is in a completely different clinic.  And some defaults and favorites can't be changed by the user, period.

Another issue is the way eCW doesn't handle lists.  Again, the problem is lack of consistency.  Example: In some parts of eCW a user can sort patients by patient name, appointment time, provider, or both provider and appointment time.  In other cases, such as pulling up charts that need to be reviewed, the user cannot sort the list (by name, encounter date, provider, or anything else)... and worse, the list that does appear is sorted randomly.  Many people review their pending charts by patient name or by how long they've been pending.  You can't do this in eCW except by paging through the entire pending list until you find the charts you need.  And that's been made more difficult by the limit on how many charts are displayed - which defaults to 15 every time you bring up the list, and reverts to 15 and has to be changed again every time you come back to the list (another default that users have to change every time they access something).

eCW also opens a lot of windows.  This might be OK - after all, the workstations are Windows-based - but you cannot go from window to window.  If you have opened up 5 windows and need to go back to window #2, you have to close windows #5, #4, and #3 in that order.  And in many cases, such as looking at one part of a progress note while writing another, you must go back and forth between windows.  If you need information in window #1 to complete something in window #5 you may have to open windows #2, 3, 4, and 5 and close windows #5, 4, 3, and 2 several times.

And, finally, eCW apparently shuts down by crashing.  No kidding.  When you exit eCW, you almost always get a message from Windows saying that eCW encountered a problem and had to shut down.  Really, now ... aren't there better ways to stop a computer program?  And is there a way for us poor users to know whether eCW actually shuts down cleanly enough that it doesn't lose our data?


2.) Terrible training

eCW sent some of their personnel to our facility to train faculty, residents, and staff how to use eCW.  The trainers may or may not have known very much about their company's software, how it works, and how to use it.  If they did, it wasn't obvious.  Some of the trainers themselves had trouble using the software.  And, just to waste more of out time, many of the trainers spent their time - and ours - telling us that features they were telling us about were ones that we would never need to use - or worse, that we would not be allowed to use.


3.) Unacceptible limitations

a.) Prescribing a medication in two or more different strengths

eCW does not allow a doctor to prescribe the same medication more than once for a single diagnosis or in a single encounter.  This is idiocy.  Many medications MUST be prescribed in doses other than those the drug company manufactures, and often the only way to do this is to prescribe the medication in two different strengths and have the patient take one of each at the same time.  eCW makes this impossible.  The kluge (solution is too good a term) is to prescribe the second dosage form in a separate encounter.  As I said: this is idiocy.

b.) Visits with multiple providers

Some facilities have clinics for patients with complicated medical problems, where several different specialists see a patient in one visit.  eCW recognizes exactly one "encounter" with one provider per patient visit.  If there are multiple providers, it's hard, if not impossible, for every provider to enter clinical data, or to bill, for his or her services - and potentially any provider can lock the encounter note, preventing other providers from entering or amending their notes.


4.) Violations of Federal and state law (HIPAA, narcotics laws, ...)

a.) Perpetual sessions with no automatic timeouts.

HIPAA, particularly the HIPAA Security Rule, REQUIRES automatic suspension of an EHR session when a terminal is idle for more than a certain amount of time.  The idea is to avoid bystanders (patients, family members, unauthorized staff, ...) from being able to see protected patient data.  The Security Rule does not specify a particular time limit (5 to 10 minute limits are common), but it requires an EHR system to suspend after a reasonable time limit and not allow the user back in without a password.

Most EHRs do that.  eCW doesn't.  I've seen sessions sit open for hours unless the user's computer times out itself.  Apparently eCW tries to comply with the auto-suspend rule by relying on the computer timing out, but if even one publicly available computer is left running unattended long enough, the practice and its doctors have no defense against fines or lawsuits by pissed-off patients.

eCW does have a "lock" command in its main menu (which seems to be completely optional).  One of the two choices on the menu locks the entire computer.  (Hopefully you need a password to let you back into the computer.)  The other choice locks the eCW session -- but when the session is locked, the patient data on the screen is NOT blanked out.  The only change on the screen is that a little window appears in the center of the screen asking for a user ID and password.  The window blocks only a small fraction of the screen, leaving the rest of the screen - possibly a patient note, complete with identifiers - visible to anyone who can see the screen.

b.) Prescription insecurity.

eCW also does not require a second password entry when prescriptions are written, whether they are printed on paper or sent electronically.  This means that ANYONE can walk up to a computer running an eCW session and enter a prescription for ANY drug for ANY patient.  If that person can also get to the prescription printer, he can grab the printed prescription, scribble something on the signature line, and have it filled.  He might have a problem if the drugstore he goes to knows the doctor who supposedly wrote the prescription, or at least what the doctor's signature looks like, but if he goes to a drugstore some distance from the office he may easily get away with the meds.  He could also send the prescription electronically: at least eCW will not fax a prescription for a controlled substance, but if the practice has set up secure e-prescriptions it's possible he could get really good Schedule II stuff that way.  And it would be very hard, maybe impossible, to prove that the provider whose name's on the prescription didn't actually write it.  This "feature" is software stupidity at its finest, and could land an eCW customer in jail.


From the little we've seen so far, my rant may be just the tip of the iceberg.  My advice: if you're thinking about using eCW, don't.  And if you're already an eCW user, get rid of it as fast as you can.

United States gwat44

For those of you who are having issues with the installer of eCW client, I have found these things to be a must when installing eCW client

Any Previous versions must be removed
if reg of dll files are failing, most likely its due to UAC(User Access Control). Disable and restart the computer and try the install again. But make sure you remove all files that pertain to the failed install including the folders under the root of C:\

My take on eCW is crap. I come from a software design and programming background and if I produced this product for a client I would be embarresed. Also, if you want custom reporting good luck as they will not tell you the structure of the database. The reporting inside eCW is a joke and is candid.

The next thing about eCW that is horrible is their support. Not only are they Most from India but they have a thick accent and you cant understand them. Their support portal is also a joke with ticketing and their Live Chat is worthless. If you are thinking of using this product I would highly advise you to use anyone else.

United States brentk

Thanks for the reply posts on this, but please don't use this post to bash ECW, every EHR has its bad points and its good points, tell me what you like as well.

EDIT: Just upgraded(8/2013) and the new blog engine has really good spam protection, now i get 1 or two spams a week.  

United States Suzie

This is the worst company ever created.  They have no knowledge of HL7, which in healthcare is required.  Their customer service is not existent.  We have had issues open with them for, literally, years.  

I would tell anyone and everyone, to run in the other direction if your doctors want this software.  It is a nightmare for the IT folks and breaks consistently.

We also had an incident where our SAM (project manager), had quit and we were not notified. It was two weeks before we found out and we found out on our own.

Every hospital/clinic that I know has had the exact same issues that we have.  I believe we all need to get together and file a class action lawsuit.  Their incompetence causes patient safety issues on a consistent basis.  We have had to stop payments to finally get a response from them.  

United States Brent

Wow suzie, sounds like a rough time.  I can agree on the SAM issues, they seem to not be able to keep them, we have had 4-5 five since we first went live with ECW.  Each time we get a new one, we have to then train them on our needs as an organization, so i can see how that would be frustrating.  The last time we changed, they handed off, i wonder what went wrong with yours.

As far as support goes, I cant mirror the comments, i would say their support response time and completeness of resolution has significantly improved since i originally wrote the article.  They have really become hands on with the folks that self host and thats not only my company, everyone in IT that i talk to who also self hosts.  I dont have any experience in the ecw hosted realm though, i do know they are much more restrictive on what you can do and there are many factors as to why the service can have problems, many of which are mitigated by self hosting.

As far as HL7 goes, i am not sure whats going on there.  We have had several projects involving HL7 interfaces(lab and pharmacy) that they have completed successfully.  While some things are not 100% of what we wanted, many times its due to whats available in the translation, you have to remember that HL7 is a two way street.  

I try to stay neutral on this stuff as every company has its ups and downs.  I only respond with what i know and what my experiences have been.  As i said, we are self hosted, so maybe that is the difference.  Realistically, overall, they have improved many things in both the software and customer service since we went live.  They have maintained their HITs certification and have created an IPAD app for the providers.  Perhaps they tend to concentrate too much on provider feedback from time to time, but they are primary users, their time is money.

My suggestion at this point, if you truly are frustrated, go to the user conference in Texas this year(next month i think), find those in charge and voice your concerns.  They will listen and hopefully be able to respond in some meaningful way.  If anything you can gain a contact who you can lean on when your SAM is not being responsive.  Have your IT person go to the IT sessions(usually on the last day of the conference) and they can interact with those in charge of IT at ecw directly.

I wish support didnt require so much effort but EHRs are complicated by nature, maybe one day this will be solved, but until then, just keep on them.

United States Mike

Hi Brent,

I'm hoping that you can point me at something different to look at.  We have multiple eCW environments, each servicing 5-6 different practices.  Each has a front end Tomcat server, a DB server and an FTP server.  Fax servers are shared by multiple environments.  Each Practice has an onsite machine for fax capability as well.

We are CONSTANTLY chasing complaints that ecw froze, crashed or is just plain slow.  From Network Engineering we have fine tuned, upgraded, replaced, tune again and QoS'd the network to the point where the only way we can make it run any better would be to shut it down yet the complaints continue to come in.

I've found some inconsistencies in the client configuration files, for example some have all the fields filled in with a server name where others only have a couple.  Some are behind the ecw certified Array Load Balancers and others are coming in direct to the Tomcat servers.  Of the sites that complain we cannot find a common thread.  Some are on VPN, some are on T3, some are on the LAN.  

eCW support and our in house applications folks insist that the problem is not on the server side yet.  In fact of the practices complaining some are MyISAM some are InnoDB.  

I'd really like to find the root cause as we are about to go through a massive rebuild to move it onto Windows and SQL behind F5 load balancers which will introduce a whole new set of variables.

Any thoughts or more information I can provide that might help you formulate some kind of guess where we should focus?

United States Brent

By SQL, i will assume MSSQL.  Virtual or physical environment?

1. All your servers should be INNODB, MyISAM has been known to cause random slowness.  The first thing i do is ask users at the main location who are local to the database and tomcat servers, if they have experienced any slowness.  If so, i check the slow query log on the MySQL database and engage ECW.  They can look at the log and address any queries that are running hard on the system.  If you are virtualized, i would get vmware on the system to make sure their are no IO latency issues, also look into this if you use a SAN to host the databases.

Also, make sure your billing staff and reporting staff are not running their queries during the practices peak times.  In fact, if you can, install a secondary instance of tomcat(ecw will do this for you cheap) and point those users to it.  Many times they are responsible for lagging the tomcat server instance everyone is using.  Tomcats should also be limited to 75 users per instance, 50 if you want to feel more comfortable.  this could be enforced at the load balancer level

2. QoS is only as good as your bandwidth.  The recommendations that ECW puts out for speed is strictly based on their application, they assume they are it.  This means voice, internet, file shares, etc are not included in that transfer speed.  It important to prioritize the tomcat servers over the ftp server(and everything else really).  Do you have x-ray( dental and/or medical ).  Do you use dental, this application adds a lot of  traffic and i believe is not included in their requirements(yet).

3. Wireless or wired or both, who is complaining?  If wireless, the buildings should be heat mapped to ensure they have proper coverage(especially with doors closed).  Wireless cards also have some affinity settings that need to be adjusted to make sure the card is not bouncing around too much between access points.  Also make sure a higher weight is given to wireless than wired if docking stations are plugged into the network, without that stations will swap back and forth(assuming you have wireless N and  a 100Meg or higher LAN ).

4. File sizes ( an issue that QoS can only mitigate ), ensure that staff are not scanning documents in full color( recommended size is 200x200 black&white ), color should only be used for ids that do not scan well.  Make sure your ECW forms are not large, staff pull them across the wire constantly.  I run a search on the FTP directory for file sizes for anything over 100MB, then i work my way down to 2MB.

5. PC's, are they up to the task of running ECW and other applications at the same time?

6. Have you considered silverpeak/riverbed network data compression and caching appliances?  Both have virtualized appliances that are cheaper than physical.  The caching of data is the real benefit when it comes to ECW because many times users upload data and the providers/nurses/other download it minutes later.

7. We have also found that if a user has a bad install of ECW( it just happens, not sure why ), you can delete the eclinicalworks folder and then reinstall the application.  On a related note, you might need to wipe their user profile as well.

8. As far as configuration files go, we use one file from one source.  If you can use a GPO, you could copy the configuration file to each workstation(powershell could do this as well which might be better based on your environment ).

United States Peter

Good article, I have some notes to add to it for potential future users.

1) The cloud solution they provide seems to work well based on discussions with folks in the local community.
2) The hosted version is a completely different story. The ECW support team is the worst team to work with. I wish it was a linguistics issue with the support personnel, but it's much deeper than that. The "technicians" assigned to tickets never get communicated anything from the project managers or their managers. They never stay to finish what they started, which causes even longer outages/service degradation.

I have been trying to figure out a way to bring all support in house, including their software patch management, etc.

Does anyone know how to get access to the latest release builds without having to work with their horrific support?  Thanks in advance.

United States Bob

Great article and thread.

Our 20+ provider / 70K patient practice is moving extremely fast on changing EHR/PM's and eCW has risen to one of the top contenders.  What is the quickest way one can determine weather to host or use their cloud/SaaS service when performance is the key factor?

We have (limited) house systems experience (including Linux)and manage our current EHR and PM (separate); however, the decision maker will be performance accessing 'larger' charts.

Thoughts?

United States Brent

Hey Bob,

You are right in that "tough decision" spot.  If you know you are going to grow in the next 5 years to around 25 or so providers, i would highly suggest you host it internally.  There are some factors to consider though(btw the post above is years out of date):

1. Network:  Does each site connect via dedicated WAN to the hosting location OR do you connect to the internet and VPN over?  If WAN, is it cheaper and easier for you to increase the connections for your WAN versus your Internet pipes?  Keeping in mind that the bandwidth they recommend per location is ONLY for ECW, it doesnt include any other traffic.

2. What kind of knowledge does your in house team have?  If you are going to host in house, i recommend you go virtual.  VMWare is their chosen platform of choice for virtualization(which at that size is the perfect application).  There was some talk about KVM at the IT summit, but nothing solid.  The key to virualization is knowing how to do it correctly and having competent staff who know when to bring in the tech support folks.  I have heard HyperV works too.  If you arent comfortable with virtualization, then your only option is physical which gets costly quick but is easier to performance troubleshoot as there is hypervisor layer to deal with.
2a. ECWs infrastructure expands and contracts, so you will have at a minimum:  database server(go mssql), report server(if you buy it), application server(s)(usually 2 min), FTP/file server, Interface server, fax server and if you have dental, a dental server.  They might give you a break and install the interface server instance on an application server which would save you a box.  This is basically why virtualization is better, buy two big hosts that can run the whole thing, then you can do fault tolerance, maintenance, DRS, live migrations without downtime.
3. Does your hosting location have a generator?  This is more applicable if you are in an area prone to power outages, but is also a worse case for outage duration.
4. back to networking:  if WAN, does your WAN provider allow you to control traffic or provide QoS services?  Would you consider purchasing compression devices?  If you go to two application servers, are you willing to purchase a load balancer(or pair for redundancy)?
5. How confident in your IT staff are you?  if really confident, being able to roll your own is far better when it comes to ensuring up time as you can actually fell and touch the systems.  You can hire external folks to verify and dig deep if need be.  You can roll your own hardware configurations to really put the speed into it.
6. If you do roll your own, join the ECW linked in technology group for answers and live one on ones with ECW people in the know.

There are people on the linked in group who are using SSDs in raid 10 configurations for their database and syncing to SAN based systems.  We run a self tiering NAS from Nimble that incorporates flash/RAM/SSDs/SATA.  You can get really crazy with the hardware to ensure performance and its not always a budget issue( i typically recommend everyone to lease equipment, especially if virtualizing. )  

Bottom line:  Hosting your own gives you the control, but its costly to the organization to maintain.

Comments are closed